A nurse is preparing to suction secretions from a patient who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Use a resuscitation bag with 80% oxygen prior to the procedure.

Select a suction catheter that is half the size of the lumen.

Place the end of the suction catheter in water-soluble lubricant.

Adjust the wall suction apparatus to a pressure of 170 mm Hg.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Using a resuscitation bag with 80% oxygen prior to the procedure is inappropriate. While pre-oxygenation is important before suctioning to prevent hypoxia, the oxygen concentration should be 100%, not 80%. Normal oxygen saturation levels are 95% to 100%. Pre-oxygenating with 100% oxygen ensures the patient maintains adequate oxygenation during the brief suctioning period. Using 80% oxygen does not fully optimize oxygen reserves for this purpose.

Choice B rationale: Selecting a suction catheter that is half the size of the tracheostomy lumen is appropriate. This size prevents excessive occlusion of the airway, ensuring adequate airflow during suctioning. The correct catheter size minimizes trauma to the tracheal mucosa and prevents hypoxia. The catheter should not exceed 50% of the tracheostomy diameter to maintain proper airway function, making this the correct action for safe and effective suctioning.

Choice C rationale

Placing the end of the suction catheter in water-soluble lubricant is not recommended. This could introduce bacteria into the airway and increase the risk of infection.

Choice D rationale

Adjusting the wall suction apparatus to a pressure of 170 mm Hg is not correct. The recommended suction pressure for adults is usually between 80 and 120 mm Hg. Suctioning at too high a pressure can cause trauma to the airway.

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Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

Pupil clarity is not typically used to assess an older adult client’s risk for falls. It is more relevant in neurological assessments.

Choice B rationale

The appearance of gait is a crucial factor in assessing an older adult client’s risk for falls. Abnormalities in gait can increase the risk of falls.

Choice C rationale

Visual fields are important in assessing an older adult client’s risk for falls. Impaired visual fields can increase the risk of falls.

Choice D rationale

Visual acuity is important in assessing an older adult client’s risk for falls. Poor visual acuity can increase the risk of falls.

A. Biofeedback B. Aloe C. Feverfew D. Acupuncture

Correct Answer is D

Explanation

Choice A rationale

Biofeedback is a mind-body technique that helps individuals gain control over bodily processes that are normally involuntary. It is not contraindicated for a client with herpes zoster.

Choice B rationale

Aloe is a plant-based product often used for its soothing and healing properties. It is not contraindicated for a client with herpes zoster.

Choice C rationale

Feverfew is a medicinal herb often used for its anti-inflammatory properties. It is not contraindicated for a client with herpes zoster.

Choice D rationale

Acupuncture involves the insertion of thin needles into specific points on the body. It is contraindicated for a client with herpes zoster because it could potentially open a portal on the skin’s surface, increasing the risk of further infection.

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A nurse is preparing to suction secretions from a patient who has a new tracheostomy. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult client’s risk for falls.Which assessments should the nurse use to identify the client’s safety needs? (Select all that apply)

Correct Answer is ["B","C","D"]

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Correct Answer is D

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